328
Letters to the Editor
promptly to penicillin therapy, the treatment o f choice. We would suggest that in those areas where Lancefield grouping is not routinely done, these children should be treated on clinical signs with evidence of hemolysis on a sheep blood agar plate, since complications of streptococcal disease have been reported as indicated by the authors. It appears that group C hemolytic streptococci is prone to infect persons in close contact, and they should be screened for the organism. Eric Kaplan, M.D. Michael Nussbaum, M.D. 1. Ronald Shenker, M.D. Marie Mundav, R.N. Hemy D. Isenberg, Ph.D. Division of Adolescent Medicine Department of Pediatrics Long Island Jewish-Hillside Medical Center New Hyde Park, N Y School of Medicine, Health Sciences Center State Universi(~' qf New York at StonF Brook REFERENCE
1,
Benjamin JT, and Perriello VA Jr: Pharyngitis due to group C hemolytic streptococci in children, J PEDIATR 89:254, 1976.
Reply To the Editor: We appreciate the comments of Kaplan and colleagues. We agree that screening of family members should be done if a child has non-group A beta hemolytic streptococcal pharyngitis. All of our patients infected with group C streptococcus received antibiotics; all symptomatic patients seemed to respond quickly to this treatment. Consequently we are now treating all patients with non-group A streptococcal pharyngitis with antibiotics. However, we recognize that for several reasons this antibiotic treatment may not be necessary. First, there has been no controlled study performed that shows that antibiotics shorten the clinical course of group C pharyngitis. Also, there is no evidence that antibiotic treatment would prevent the sequelae of group C pharyngitis. John T. Benjamin, M.D. 1011 E. Jefferson St. Charlottesville, VA 22901
Nonhemolytic group B streptococcal infections To the Editor." We would like to add some additional information to that recently provided by Roe and associates ~ in their article on nonhemolytic group B streptococcal infections.
?-he Journal of Pediatrics February 1977
Since our first recognized case of neonatal disease due to a nonhemolytic group B streptococcus about two years agos we have done hippurate tests on atl nonhemolytic streptococci obtained from the blood or cerebrospinal fluid o f pediatric patients. In the two-year period we detected one additional nonhemolytic group B streptococcus (serotype 11I) in the blood of a 4-week-old infant with clinical sepsis. The organism was hippurate and CAMP positive and nonhemolytic after aerobic culture on 5% sheep blood agar (stabbed) for one week. Catalase, bacitracin, methicillin, and bile-esculin tests were negative, and no growth occurred in 6.5% NaC1. Over this same time period, isolates of beta-hemolytic group B streptococci were obtained from the blood or cerebrospinal fluid of 35 pediatric patients. Thus 5.4% (or 2 out of 37) of the patients were infected by nonhemolytic group B streptococci. This contrasts with the 36% rate (or 4 out of 11) reported by Roe and colleagues for a 3-year period and would appear to broaden the range of incidence that might be expected by a laboratory alert to this problem. We would agree with the recommendations for evaluation of streptococci made by Roe and colleagues, even though the yield of nonhemolytic isolates may vary in different locations. Arthur L. Frank, M.D. Departments of Pediatrics and Epidemiologv and Public Health Alexander yon Graevenitz, M.D. Department of Laboratorr' Medicine Yale Universi(v Schoo[ o f Medicine New Haven, CT 06510 REFERENCES
1. Roe MH, Todd JK, and Favara BE: Nonhemolytic group B streptococcal infections, J PEOIATR 89:75, 1976. 2. Frank AL, and yon Graevenitz A: Septicemia and meningitis in a newborn due to a nonhemolytic group B streptococcus, Infection 3:60, 1975.
Re&vance of concentration of pathogenic bacteria in cerebrospinal fluid to antibiotic therapy To the Editor: The report of bacterial counts in cerebrospinal fluid of patients with bacterial meningitis by Dr. Feldman' is an important one: however, we would like to comment on his point that large inocula of group B streptococci markedly elevated the minimal inhibitory concentration (MIC) for antibiotics. We followed his study by examining the antibiotic susceptibility of each of the five clinical isolates o f Hemophilus influenzae type b and group B streptococci. The MIC was determined by tube dilution according to the method described by the author. As shown in Table I, the MIC values for ampicillin, penicillin G, and chloramphenicol against H. influenzae agreed with his results. An "inoculum effect" was observed, and the MIC of ampicillin and penicillin G for this organism increased from O.25
Letters to the Editor
promptly to penicillin therapy, the treatment o f choice. We would suggest that in those areas where Lancefield grouping is not routinely done, these children should be treated on clinical signs with evidence of hemolysis on a sheep blood agar plate, since complications of streptococcal disease have been reported as indicated by the authors. It appears that group C hemolytic streptococci is prone to infect persons in close contact, and they should be screened for the organism. Eric Kaplan, M.D. Michael Nussbaum, M.D. 1. Ronald Shenker, M.D. Marie Mundav, R.N. Hemy D. Isenberg, Ph.D. Division of Adolescent Medicine Department of Pediatrics Long Island Jewish-Hillside Medical Center New Hyde Park, N Y School of Medicine, Health Sciences Center State Universi(~' qf New York at StonF Brook REFERENCE
1,
Benjamin JT, and Perriello VA Jr: Pharyngitis due to group C hemolytic streptococci in children, J PEDIATR 89:254, 1976.
Reply To the Editor: We appreciate the comments of Kaplan and colleagues. We agree that screening of family members should be done if a child has non-group A beta hemolytic streptococcal pharyngitis. All of our patients infected with group C streptococcus received antibiotics; all symptomatic patients seemed to respond quickly to this treatment. Consequently we are now treating all patients with non-group A streptococcal pharyngitis with antibiotics. However, we recognize that for several reasons this antibiotic treatment may not be necessary. First, there has been no controlled study performed that shows that antibiotics shorten the clinical course of group C pharyngitis. Also, there is no evidence that antibiotic treatment would prevent the sequelae of group C pharyngitis. John T. Benjamin, M.D. 1011 E. Jefferson St. Charlottesville, VA 22901
Nonhemolytic group B streptococcal infections To the Editor." We would like to add some additional information to that recently provided by Roe and associates ~ in their article on nonhemolytic group B streptococcal infections.
?-he Journal of Pediatrics February 1977
Since our first recognized case of neonatal disease due to a nonhemolytic group B streptococcus about two years agos we have done hippurate tests on atl nonhemolytic streptococci obtained from the blood or cerebrospinal fluid o f pediatric patients. In the two-year period we detected one additional nonhemolytic group B streptococcus (serotype 11I) in the blood of a 4-week-old infant with clinical sepsis. The organism was hippurate and CAMP positive and nonhemolytic after aerobic culture on 5% sheep blood agar (stabbed) for one week. Catalase, bacitracin, methicillin, and bile-esculin tests were negative, and no growth occurred in 6.5% NaC1. Over this same time period, isolates of beta-hemolytic group B streptococci were obtained from the blood or cerebrospinal fluid of 35 pediatric patients. Thus 5.4% (or 2 out of 37) of the patients were infected by nonhemolytic group B streptococci. This contrasts with the 36% rate (or 4 out of 11) reported by Roe and colleagues for a 3-year period and would appear to broaden the range of incidence that might be expected by a laboratory alert to this problem. We would agree with the recommendations for evaluation of streptococci made by Roe and colleagues, even though the yield of nonhemolytic isolates may vary in different locations. Arthur L. Frank, M.D. Departments of Pediatrics and Epidemiologv and Public Health Alexander yon Graevenitz, M.D. Department of Laboratorr' Medicine Yale Universi(v Schoo[ o f Medicine New Haven, CT 06510 REFERENCES
1. Roe MH, Todd JK, and Favara BE: Nonhemolytic group B streptococcal infections, J PEOIATR 89:75, 1976. 2. Frank AL, and yon Graevenitz A: Septicemia and meningitis in a newborn due to a nonhemolytic group B streptococcus, Infection 3:60, 1975.
Re&vance of concentration of pathogenic bacteria in cerebrospinal fluid to antibiotic therapy To the Editor: The report of bacterial counts in cerebrospinal fluid of patients with bacterial meningitis by Dr. Feldman' is an important one: however, we would like to comment on his point that large inocula of group B streptococci markedly elevated the minimal inhibitory concentration (MIC) for antibiotics. We followed his study by examining the antibiotic susceptibility of each of the five clinical isolates o f Hemophilus influenzae type b and group B streptococci. The MIC was determined by tube dilution according to the method described by the author. As shown in Table I, the MIC values for ampicillin, penicillin G, and chloramphenicol against H. influenzae agreed with his results. An "inoculum effect" was observed, and the MIC of ampicillin and penicillin G for this organism increased from O.25
